THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY PASHINSKI, DeLUCA, BOBACK, BRIGGS, CALTAGIRONE, FABRIZIO, FRANKEL, GEORGE, HALUSKA, HARKINS, HORNAMAN, JOHNSON, KORTZ, KULA, MANN, M. O'BRIEN, PAYTON, SANTARSIERO, SANTONI, K. SMITH, STURLA, SWANGER, VULAKOVICH, WAGNER AND YOUNGBLOOD, MARCH 1, 2011

REFERRED TO COMMITTEE ON INSURANCE, MARCH 1, 2011  

AN ACT

Establishing the Pennsylvania Health Information Exchange

Authority and the Health Information Technology Fund; and

providing for grants and loans for health information

technology and for duties of the Department of Community and

Economic Development.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

CHAPTER 1 

PRELIMINARY PROVISIONS

Section 101.  Short title.

This act shall be known and may be cited as the Health

Information Technology Act.

Section 102.  Definitions.

The following words and phrases when used in this act shall

have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Clinical decision support system."  An interactive computer

system that assists health care providers in applying new

information to patient care through the analysis of patient-

specific clinical variables.

"Community-based health care clinic."  A nonprofit health

care center located in this Commonwealth providing comprehensive

health care services without regard for a patient's ability to

pay and:

(1)  meets either of the following criteria:

(i)  serves a federally designated medically

underserved area, a medically underserved population or a

health professional shortage area; or

(ii)  serves a patient population with a majority of

that population having an income less than 200% of the

Federal poverty income guidelines; and

(2)  includes any of the following:

(i)  a federally qualified health center as defined

in section 1905(1)(2)(B) of the Social Security Act (49

Stat. 620, 42 U.S.C. § 1396d(1)(2)(B)) or a federally

qualified health center look-alike;

(ii)  a rural health clinic as defined in 1861(aa)(2)

of the Social Security Act (49 Stat. 620, 42 U.S.C. §

1395x(aa)(2));

(iii)  a hospital outpatient clinic certified by

Medicare;

(iv)  a free or partial-pay health clinic that

provides medical home and primary care services by

volunteer and nonvolunteer health care providers; or

(v)  a nurse-managed health care clinic that is

managed by advanced practice nurses, a federally

qualified health center or an independent nonprofit

health or social services agency.

"Department."  The Department of Community and Economic

Development of the Commonwealth.

"Fund."  The Health Information Technology Fund established

in section 503.

"Health care facility."  A health care facility as defined

under section 802.1 of the act of July 19, 1979 (P.L.130,

No.48), known as the Health Care Facilities Act, or an entity

licensed as a hospital under the act of June 13, 1967 (P.L.31,

No.21), known as the Public Welfare Code.

"Health care provider."  A person licensed by the

Commonwealth to provide health care or professional medical

services. The term includes, but is not limited to, a physician,

a dentist, a pediatrician, a certified nurse midwife, a

podiatrist, a certified registered nurse practitioner, a

physician assistant, a skilled nursing facility, nursing home,

home health entity, a community-based health care clinic and

community mental health center.

"Health informatics."  Any of the following:

(1)  The electronic exchange of health care information

among entities in the health care system, including, but not

limited to:

(i)  Physicians and other health care providers.

(ii)  Health insurance companies and health

maintenance organizations.

(iii)  Federal and State government health payers.

(iv)  Employers.

(v)  Pharmacies and pharmacy benefit managers.

(vi)  Laboratories.

(vii)  Public health agencies. 

(2)  The provision of the most current, complete and

accurate information possible when making health care

decisions regarding patients.

(3)  The sharing and exchange of health care information

among organizations that are owners or custodians of the

health care information.

(4)  The use of information technology to enable and

improve the exchange and presentation of health care

information.

(5)  The adoption and use of electronic medical record

technology, where appropriate, within the health care system.

(6)  The reduction of total health care costs through

improved quality and reduction in redundancies and

administrative waste.

"Health information."  Information that:

(1)  is created or received by a health care provider,

health plan, public health authority or health care

clearinghouse; and

(2)  relates to the past, present or future physical or

mental health or condition of an individual, the provision of

health care to an individual or the past, present or future

payment for the provision of health care to an individual.

"Health information exchange" or "HIE."  The electronic

movement of health-related information among organizations

according to nationally recognized standards.

"Health information technology."  Hardware, software,

integrated technologies or related licenses, intellectual

property, upgrades or packaged solutions sold as services that

are designed for or support the use by health care entities or

patients for the electronic creation, maintenance, access or

exchange of health information.

"Health information technology regional extension center."  A

United States-based nonprofit institution or organization or

group of nonprofit institutions or organizations, meeting the

requirements established by the Office of the National

Coordinator and created to:

(1)  Encourage adoption of certified electronic health

records by clinicians and hospitals.

(2)  Increase the probability that adopters of electronic

health record systems will become meaningful users of the

technology.

(3)  Assist clinicians and hospitals to become meaningful

users of electronic health records.

"Health information technology system."  The secure use of

information and communication technology that may include:

(1)  electronic health records;

(2)  personal health records;

(3)  e-mail communication;

(4)  clinical alerts and reminders;

(5)  clinical decision support systems; or

(6)  other technologies that store, protect, retrieve and

transfer clinical, administrative and financial information

electronically within health care settings.

"Health insurer."  Any of the following providers of health

care insurance coverage:

(1)  an insurer licensed under the act of May 17, 1921

(P.L.682, No.284), known as The Insurance Company Law of

1921;

(2)  a health maintenance organization as defined in

section 3 of the act of December 29, 1972 (P.L.1701, No.364),

known as the Health Maintenance Organization Act; or

(3)  a nonprofit health plan corporation operating under

40 Pa.C.S. Chs. 61 (relating to hospital plan corporations)

and 63 (relating to professional health services plan

corporations).

"Interoperability."  The ability of different information

technology systems and applications to exchange data securely,

accurately, effectively and in a manner that maintains and

preserves the clinical purpose of the data.

"National Coordinator."  The head of the office of the

National Coordinator of Health Information Technology.

"Program."  The Health Technology Program established in

Chapter 3.

"Protected health information."  Protected health information

under 45 CFR Parts 160 (relating to general administrative

requirements) and 164 Subpts. A (relating to general provisions)

and E (relating to privacy of individually identifiable health

information).

"Qualified electronic health record."  An electronic health

record that has been generated under the Recovery and

Reinvestment Act of 2009 (Public Law 111-5, 123 Stat. 115) and

that is applicable to the type of record involved.

CHAPTER 3

PENNSYLVANIA HEALTH INFORMATION EXCHANGE (PHIX)

Section 301.  Scope of chapter.

This chapter relates to facilitating and assisting in the

development and operation of a Statewide health information

exchange.

Section 302.  Definitions.

The following words and phrases when used in this chapter

shall have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Authority."  The Pennsylvania Health Information Exchange

(HIE) Authority established under section 303(a).

"Board."  The board of directors of the Pennsylvania Health

Information Exchange (PHIX) Authority established under section

303(b).

Section 303.  Establishment of the Pennsylvania Health

Information Exchange Authority.

(a)  Establishment.--There is established a body corporate

and politic to be known as the Pennsylvania Health Information

Exchange (PHIX) Authority.

(b)  Board.--The powers and duties of the authority shall be

vested in and exercised by a board of directors.

(c)  Board composition.--The board of the authority shall

consist of members, appointed in accordance with the following:

(1)  An individual appointed by the Governor from a list

of three qualified individuals with experience in health

informatics recommended by a technology industry organization

operating and based in Pennsylvania.

(2)  Four Commonwealth residents with an expertise in

health informatics. Each of the following persons shall

appoint one person:

(i)  The President pro tempore of the Senate.

(ii)  The Minority Leader of the Senate.

(iii)  The Speaker of the House of Representatives.

(iv)  The Minority Leader of the House of

Representatives.

(3)  Three physicians, one of whom shall be appointed by

the Majority Leader of the Senate, one of whom shall be

appointed by the Minority Leader of the Senate, and one of

whom shall be appointed by the Majority Leader of the House

of Representatives, from a list of six qualified licensed

physicians recommended by the Pennsylvania Medical Society

and the Pennsylvania Osteopathic Medical Association. Each

shall serve initial terms of three years. One appointee shall

be from a practice employing ten or fewer physicians. One

appointee shall be from a rural practice. One appointee shall

be part of a large urban or suburban practice of 51

physicians or more.

(4)  Seven individuals with expertise in health

informatics appointed as follows:

(i)  Two individuals representing a community-based

health care clinic, one of whom from a federally

qualified health center. One shall be appointed by the

Majority Leader of the Senate and one shall be appointed

by the Majority Leader of the House of Representatives.

(ii)  Three individuals recommended by the Hospital

and Healthsystem Association of Pennsylvania, one of whom

shall be a representative of rural hospitals. One shall

be appointed by the President pro tempore of the Senate

and one appointed by the Speaker of the House of

Representatives. The remaining individual shall be the

representative of rural hospitals and appointed by the

Majority Leader of the House of Representatives.

(iii)  One representative of the Blue Cross and Blue

Shield plans in Pennsylvania, appointed by the Minority

Leader of the Senate.

(iv)  One representative of a licensed insurer other

than a Blue Cross or Blue Shield plan, appointed by the

Minority Leader of the House of Representatives.

(5)  The Secretary of Public Welfare or a designee.

(6)  A representative of consumers who is not primarily

involved in the provision of health care or health care

insurance appointed by the Minority Leader of the House of

Representatives.

(7)  Two individuals appointed by the Governor, one with

expertise in privacy and the other with expertise in health

information security.

(d)  Terms.--Members of the board shall not serve more than

three full consecutive terms. Each board member shall serve a

term coterminous with the board member's appointing authority

unless replaced earlier by the appointing authority.

(e)  Quorum.--A majority of the members of the board shall

constitute a quorum.

(f)  Action.--Notwithstanding any other provision of law,

action may be taken by the board at a meeting upon a vote of the

majority of its members present in person or through the use of

amplified telephonic equipment if authorized by the bylaws of

the board.

(g)  Meetings.--The board shall meet at the call of the

chairperson or as may be provided in the bylaws of the board.

The board shall hold quarterly meetings which shall be subject

to the requirements of 65 Pa.C.S. Ch. 7 (relating to open

meetings). Meetings of the board shall be held within this

Commonwealth. Records of board meetings are subject to the act

of February 14, 2008 (P.L.6, No.3), known as the Right-to-Know

Law.

(h)  Chairperson.--The chairperson shall be the person

appointed under subsection (c)(1).

(i)  Formation.--The authority shall be formed within 60 days

of the effective date of this section.

(j)  Dissolution.--The authority shall be dissolved, if after

three years of operation the costs of the authority, including

salaries and necessary expenses for the proper operation and

administration of the exchange, exceed revenues, including

transaction fees for uses.

Section 304.  Powers and duties.

(a)  General rule.--The board shall:

(1)  Adopt bylaws necessary to carry out the provisions

of this chapter.

(2)  Employ staff as necessary to implement this chapter.

(3)  Make, execute and deliver contracts and other

instruments.

(4)  Apply for, solicit, receive, establish priorities

for, allocate, disburse, contract for, administer and spend

moneys in the fund under Chapter 5 and other funds made

available to the board from a source consistent with the

purposes of this chapter.

(5)  Participate with the department in applying for and

distributing grants and loans under Chapter 5.

(6)  Accept Federal grants to carry out the purpose of

the authority that includes administering grants and loans in

accordance with the terms of the grants.

(7)  Impose subscription or transaction fees for users of

the health information exchange which shall be used to pay

for the exchange's operation.

(b)  Exchange of electronic information.--The authority

shall:

(1)  Define the vision for a Statewide health information

exchange system to electronically exchange health care

information among entities in the health care system. This

shall include, but is not limited to:

(i)  Health care providers.

(ii)  Health insurance companies and managed care

organizations.

(iii)  Federal and State government health payors.

(iv)  Employers.

(v)  Pharmacies and pharmacy benefit managers.

(vi)  Laboratories.

(vii)  Public health agencies.

(2)  Encourage, facilitate and assist in:

(i)  The development of the Statewide health

information exchange system.

(ii)  The ongoing operation of the Statewide health

information exchange system, including monitoring the

performance, quality and security of the Statewide health

information exchange system.

(3)  Oversee a collaborative Statewide process using

public and private expertise to develop common polices,

clinical goals, technical requirements and architectural

standards for this Commonwealth's health information exchange

system consistent with emerging Federal requirements.

(4)  Develop policies using a collaborative Statewide

process to ensure compliance with section 305. 

(c)  Statewide health information technology plan.--The

authority shall facilitate with the department the development

of a Statewide health information technology plan that includes

the implementation of an integrated electronic health

information infrastructure for the sharing of electronic health

information among health care facilities, health care

professionals, public and private payers and patients. The

health information technology plan shall:

(1)  Support the effective, efficient, Statewide use of

electronic health information in patient care, health care

policymaking, clinical research, health care financing and

continuous improvements to quality.

(2)  Propose methods to educate the general public and

health care providers about the value of an electronic health

infrastructure for improving patient care.

(3)  Promote the use of national standards for the

development of an interoperable system, which shall include

provisions relating to security, privacy, data content,

structures and format, vocabulary and transmission protocols.

(4)  Propose strategic investments in equipment and other

infrastructure elements that will facilitate the ongoing

development of a Statewide infrastructure.

(5)  Recommend funding mechanisms for the ongoing

development and maintenance costs of a Statewide health

information system, including funding options and an

implementation strategy for a loan and grant program.

(6)  Propose to incorporate the existing health care

information technology initiatives in order to avoid

incompatible systems and duplicative efforts.

(7)  Address issues related to data ownership, governance

and confidentiality and security of patient information.

(8)  Once the Statewide health information technology

plan has been drafted, the plan shall be posted for public

comment for a period of 30 days. Written input shall be

submitted to the authority. Public comment shall be reviewed

and considered by the authority before a final plan is

adopted.

(d)  Statewide health information exchange.--The authority

shall establish Statewide health information exchange

capabilities for streamlining health care administrative

functions, including:

(1)  Communicating point-of-care services, including

laboratory results, diagnostic imaging and prescription

histories.

(2)  Communicating patient identification and emergency

room required information in conformity with Federal and

State privacy laws.

(3)  Real-time communication of enrollee status in

relation to health plan coverage, including enrollee cost-

sharing responsibilities.

(4)  Current census and status of health plan-contracted

providers.

(e)  Security measures.--The authority shall develop and

establish appropriate security standards to protect both the

transmission and the receipt of individually identifiable health

information or health care data that include:

(1)  Appropriate security standards to protect access to

any individually identifiable health information or health

care data that may be collected, assembled or maintained by

the authority.

(2)  Levels of security and protection for access to and

control of individually identifiable health information,

including mental health care data and data relating to

specific disease status that is governed by more stringent

Federal or State privacy laws.

(3)  Policies and procedures for the authority for taking

disciplinary actions against a board member, employee or

other person with access to individually identifiable health

care information that violates Federal or State privacy laws

related to health care information or data maintained by the

corporation.

(4)  Privacy, security operational and technical

standards to assist health information exchanges in this

Commonwealth to ensure effective Statewide privacy, data

security, efficiency and interoperability across networks.

(f)  Advisory panels.--The board may create any advisory

panels that the board considers useful to advise the board and

the authority on issues determined by the board. The authority

may create advisory panels to advise the board and the authority

on a particular issue. The board shall consider the interests of

the following when creating an advisory panel:

(1)  Health care provider.

(2)  Insurers.

(3)  Managed care organizations.

(4)  Health care information systems.

(5)  Hospitals and health systems.

(6)  Laboratory services.

(7)  Radiological services.

(8)  Community-based health care clinics.

(9)  Health information exchange organizations.

(10)  Pharmacies.

(11)  Dentists.

(12)  Pediatricians.

(13)  Any other health care providers.

Section 305.  Prohibited use of information.

The authority shall not engage in any of the following:

(1)  The collection and analysis of clinical data and

data relating to any individual without the express written

consent of the individual.

(2)  The comparison of health care providers to other

health care providers.

(3)  The creation of evidence-based standards for the

practice of medicine.

Section 306.  Appropriate use of information.

The authority may provide access to aggregated, de-

identified, protected health information to local health

information exchanges, Commonwealth-accredited universities and

public health departments for the purposes of disease

management, population health assessments and identifying public

health trends or incidents.

Section 307.  Annual report.

(a)  Deadline and contents.--The board shall report no later

than September 1, 2013, and annually thereafter to the General

Assembly on the activities in the preceding year. The report

shall include:

(1)  A schedule of the year's meetings.

(2)  Updates to the Statewide plan created under section

304.

(3)  Updates to privacy, security, operational and

technical standards to assist health information exchanges in

this Commonwealth to ensure effective Statewide privacy, data

security, efficiency and interoperability across networks.

(4)  A list of any grants or loans that the authority

assisted in attaining for any health care provider or health

information exchange.

(5)  A summary of the fund receipts and expenditures,

including a financial statement and balance sheet.

(b)  Distribution.--The report shall be distributed to the

Secretary of Health, the chair and minority chair of the Public

Health and Welfare Committee of the Senate and the chair and

minority chair of the Health and Human Services Committee of the

House of Representatives.

(c)  Public access.--The annual report shall be made

available for public inspection and shall be posted on the

authority's publicly accessible Internet website.

CHAPTER 5

LOANS OR GRANTS FOR INFORMATION NETWORKS PROGRAM

Section 501. Purpose.

This chapter relates to assisting health care providers in

funding for health technology information facilitating and

assisting in the development and operation of a Statewide health

information exchange.

Section 502.  Health Information Technology Program.

(a)  Establishment.--The Loans or Grants for Information

Networks (LOGIN) Program is established in the department to

administer loans or grants:

(1)  under the American Recovery and Reinvestment Act of

2009 (Public Law 111-5, 123 Stat. 115); or

(2)  from sources other than those in paragraph (1) that

shall be used to provide funding to health care providers or

health information technology regional extension centers to

encourage the adoption and implementation of health

information technology.

(b)  Eligible activities.--The program may provide grants or

loans to health care facilities, health care providers or health

information exchanges.

(c)  Grants.--Grants shall be used to conduct activities to

facilitate and expand the electronic movement and use of health

information among organizations according to nationally

recognized standards through activities that include:

(1)  Training and dissemination of information on best

practices to integrate health information technology.

(2)  Promoting the interoperability of clinical data

repositories or registries.

(3)  Promoting technologies and best practices that

enhance the protection of health information by all holders

of individually identifiable health information.

(4)  Improving the secure electronic exchange of health

information.

(5)  Improvement and expansion of the use of health

information technology by public health departments.

(6)  Providing technical assistance for the development

and dissemination of solutions to barriers to the exchange of

electronic health information.

(7)  Promoting effective strategies to adopt and utilize

health information technology in medically underserved

communities.

(8)  Assisting patients in utilizing health information

technology.

(d)  Loans.--Loans may be used for the following activities:

(1)  The purchase by health care providers and health

care facilities of qualified electronic health record

technology.

(2)  Enhancing the utilization of qualified electronic

health record that may include costs associated with

upgrading health information technology so that it meets

criteria for a qualified electronic health record technology.

(3)  Training personnel in the use of qualified

electronic health record technology.

(4)  Improving the secure electronic exchange of health

information.

(5)  Purchasing clinical decision support systems.

(e)  Limitations.--

(1)  The amount of a loan to a health care facility or

health care provider may not exceed:

(i)  $1,000,000 for a health care facility.

(ii)  $50,000 for a health care provider.

(2)  A grant under this subsection shall require a

matching commitment of 20% of the grant or loan which can be

in the form of cash or equivalent in-kind capital or

services.

(3)  No less than 25% of available funds shall be used

for loans to health care providers in counties of the fourth,

fifth, sixth, seventh or eighth class.

(4)  No less than 15% of available funds shall be used

for loans to health care providers with 50 or fewer

practicing physicians.

(f)  Loan requirement.--A loan made under this section shall

require all of the following:

(1)  Have an interest rate that does not exceed the

market interest rate.

(2)  Require the principal and interest payments on each

loan to commence not later than one year after the date the

loan was awarded.

(3)  Require each loan to be fully amortized no later

than ten years after the date of the loan.

(g)  Health information technology regional extension

centers.--Nothing in this section shall prevent a health care

provider or health care facility from using a loan received

under this section to contract for services provided by a health

information technology regional extension center.

Section 503.  Fund.

A fund is established in the State Treasury to be known as

the Health Information Technology Fund. The following shall be

deposited in the fund:

(1)  Money appropriated to the fund by the General

Assembly.

(2)  Grants and loans received under the American

Recovery and Reinvestment Act of 2009 (Public Law 111-5, 123

Stat. 115) or other Federal law.

(3)  Earnings derived from the investment of the money in

the fund after deducting investment expenses.

(4)  Loan repayments of principal and interest.

(5)  Funds derived from any other source. 

Section 504.  Application.

(a)  Submission.--In order to receive a loan or grant under

this chapter, a health care facility or health care provider

center shall submit an application in a form and manner

prescribed by the department.

(b)  Requirements.--An application submitted under subsection

(a) shall set forth the manner in which the health information

technology system will do the following:

(1)  Comply with all criteria adopted by the National

Coordinator.

(2)  Protect privacy and security of health information.

(3)  Maintain and provide permitted access to health

information.

(4)  Improve the quality of health care by reducing

health care costs, serious preventable adverse events,

medical errors, inappropriate care and incomplete information

and the coordination of care and information among health

care providers, health insurers and other entities.

(5)  Ensure interoperability with other systems and

health care providers.

(6)  Provide consumer access to personal medical

information.

(7)  Comply with all Federal and State laws and

regulations relating to security and notification of any

breach of electronic medical records.

(8)  Ensure that the health care provider or health care

facility will become a meaningful user, as determined by the

Centers for Medicare and Medicaid Services, of a qualified

electronic health record.

Section 505.  Duties of department.

(a)  Duties.--The department shall:

(1)  Administer the health information technology program

to provide grants and loans to eligible health care providers

and health care facilities.

(2)  Award grants and loans in all geographic areas of

this Commonwealth.

(3)  Require the use of standards for health information

technology that are consistent with those developed by the

National Coordinator and the Centers for Medicare and

Medicaid Services, when applicable.

(4)  Develop a grant and loan application form with input

from the Pennsylvania Health Information Exchange Authority,

the Department of Public Welfare, the Insurance Department,

the Department of Health and the Governor's Office.

(5)  Develop the criteria for awards of a grant and loan

with input from the Pennsylvania Health Information Exchange

Authority, the Department of Public Welfare, the Insurance

Department, the Department of Health and the Governor's

Office.

(6)  Provide a loan application form within 90 days of

the effective date of this section.

(7)  Ensure that health information technology policies

and programs of the department are coordinated with the

Pennsylvania Health Information Exchange Authority, the

Department of Public Welfare, the Department of Health, the

Governor's Office of Health Care Reform and other executive

branch agencies with Federal agencies.

(8)  Share appropriate data relating to the use of health

information technology systems with the Pennsylvania Health

Information Exchange Authority, the Department of Public

Welfare, the Health Care Cost Containment Council, the

Patient Safety Authority and other State agencies. Data

collected by a State agency relating to the operation of

health information technology systems in this Commonwealth

shall be shared with the department.

(9)  Give preference to applications which provide health

information technology systems that link multiple health care

providers and which provide direct patient access to health

care information.

(10)  Audit loans awarded under this act.

(11)  Provide ongoing assessment of the benefits and

costs of health information technology systems, including

information relating to reduction in medical errors,

reduction in physician visits, economic impact, efficiencies

and other information.

(12)  Develop a public information program to inform the

public of the efficiency and safety advantage of health

information technology.

(b)  Exceptions.--Federal grants or loans for health

information technology shall be administered under the

conditions and requirements in the grant.

Section 506.  Accountability.

(a)  Information required.--Within one year of the award of a

loan under this act, the recipient shall provide all of the

following to the department:

(1)  A report on the status of the strategic plan and the

development of the health information technology system.

(2)  An accounting of the expenditure of funds from the

loan and from other sources.

(3)  A report on any reductions in medical errors,

increases in efficiency and advances in the delivery of

patient-centered medical care.

(b)  Annual report.--The department shall submit an annual

report to the chair and minority chair of the Banking and

Insurance Committee of the Senate and the chair and minority

chair of the Insurance Committee of the House of

Representatives, which report shall include the number and

amount of grants and loans awarded, a description of the system

being funded, total amount of funds spent and the projected

impact on the delivery of health care.

CHAPTER 20

MISCELLANEOUS

Section 2001.  Effective date.

This act shall take effect January 1, 2013.